CASE Network Studies and Analyses 451 - The Development of Long-Term Care in Post-Socialist Member States of the EU

The Development of Long-Term
Care in Post-Socialist
Member States of the EU

CASE Network Studies & Analyses No.451 – The Development of Long-Term Care in Post …
Materials published here have a working paper character. They can be subject to further
publication. The views and opinions expressed here reflect the author(s) point of view and
not necessarily those of CASE Network.
This report was prepared within a project entitled “Assessing Needs of Care in European
Nations” (ANCIEN). The project is funded by the European Commission under the 7th
Framework Programme (FP7 Health-2007-3.2.2, Grant no. 223483).
Keywords: LTC, Formal and Informal Care, Family Care, Home Care, CEE Countries,
LTC Financing
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JEL Codes: I18, I31, J11, J18
© CASE – Center for Social and Economic Research, Warsaw, 2013
Graphic Design: Agnieszka Natalia Bury
EAN: 9788371785795
Publisher:
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e-mail: case@case-research.eu
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Contents
Abstract ............................................................................................................................... 4
Introduction ......................................................................................................................... 5
1. Future demographic changes in old and new member states of the European
Union .................................................................................................................................... 6
2. The notion of long-term care ...................................................................................... 9
3. Development of care for the elderly ..........................................................................10
4. The family–based model of long-term care for the elderly ......................................17
5. Long-term care – a female world ...............................................................................18
6. Introducing long-term care into social protection legal regulations .......................23
7. LTC organization and management ..........................................................................25
8. LTC funding ................................................................................................................27
9. Development of separate and institutionalized long-term care ...............................35
Conclusions ........................................................................................................................38
Literature.............................................................................................................................41
Annex ..................................................................................................................................45

Stanisława Golinowska, a professor of economics, is a co-founder of CASE – Center for
Social and Economic Research and Vice Chairwoman of the Council of the Foundation,
where she conducts her research. She graduated from the Faculty of Economics (Warsaw
University) and studied at the Mannheim University as a scholarship - holder of the Humboldt
Foundation. During the years 1991 – 1997 she was a director of the key research institute in
the field of the labour market and social affairs – IPiSS in Warsaw. She was also a Director
of the Institute of Public Health, Jagiellonian University Medical College (Cracow, Poland),
where she still is an academic professor and well known researcher. Stanisława Golinowska
is the author of numerous articles and books on social aspects of economics and social
policy reforms. She was the initiator and coordinator of the debate and projects on reforming
such fields as the labour market, pension system, health care, social assistance and the
development of NGOs and social dialogue. Based on that she participates in advisory and
expert works at the country and international level.
Agnieszka Sowa holds PhD in social sciences from the Maastricht University, MSc in the
field of Social Protection Financing, Department of Economics and Business Administration
of the same university as well as MA in the field of public policy from the Warsaw University,
Department of Sociology. Following participation in the World Bank project, she has been a
Center for Social and Economic Research – CASE expert since 2001. She taught social
policy and social insurances at the Institute of Public Health, Jagiellonian University in the
period of 2004-2007. Currently, she is also working at the Institute of Labour and Social
Studies in Warsaw. Her experience includes involvement in the analysis of the health care
system and health inequalities, research on labour market, poverty and social exclusion in
Poland and other countries of the region. She was an expert in numerous projects, including
projects commissioned by ILO, European Commission and OECD.
3

4
Abstract
Long-term care (LTC) in the new EU member states, which used to belong to the former
socialist countries, is not yet a legally separated sector of social security. However, the
ageing dynamics are more intensive in these states than in the old EU member states. This
paper analyses the process of creating an LTC sector in the context of institutional reforms of
social protection systems during the transition period. The authors explain LTC’s position
straddling the health and social sectors, the underdevelopment of formal LTC, and the
current policies regarding the risk of LTC dependency. The paper is based mainly on the
analysis of information provided by country experts in the ANCIEN project.

5
Introduction
Many former socialist countries, including several new EU member states (NMS) such as the
Czech Republic, Hungary, Slovakia, Slovenia, Poland, the Baltic countries, Romania and
Bulgaria, have modified their social institutions quite radically over the last 20 years. This
process occurred as they were emerging from a social policy model which had been
relatively homogeneous in terms of institutional framework, but quite diverse from the
standpoint of funding levels. Their pace of reform has varied and, moreover, their aims and
directions remain very different.
The population in the Central and Eastern European (CEE) and Commonwealth of
Independent States (CIS) regions is ageing rapidly, faster than in the countries of ‘old
Europe’ (although until recently the opposite was true). This has altered the perspective on
so-called “social issues” over the last few years. As early as in 2030 in several of the
countries, namely in the Czech Republic, Bulgaria, Slovenia and Poland, the share of people
aged 65+ will be close to the average observed in EU countries. And in 2050, the two EU
countries which currently have relatively young populations, Poland and Slovakia, will be in
the oldest category.
The impending social and economic challenges which European countries face due to the
high rate of population aging are extremely serious. Efforts are focused on the future. As a
first step, reforms of income security for the elderly were introduced in the form of changes to
the pension system. Next, health care, and now long-term care (LTC), are being analyzed
and reformed. In the NMS, LTC is not the most broadly discussed issue1 and solutions in this
area tend to be more traditional.
This paper aims to draw attention to the issue of LTC, the missing link in the social protection
systems of the NMS. It has been prepared on the basis of work and discussions within the
ANCIEN project (Assessing Needs of Care in European Nations), especially the first and last
of its thematic packages (Workpackage I - Riedel, Kraus 2011, Workpackage VII – Mot, Birko
2012). In these packages, a classification of the solutions used in European countries was
drawn up, and ways of identifying and evaluating the development of various forms of long-term
care were studied. It turned out that the criteria used in the analyses and classification
based on modest quantitative data did not always give clear results and required qualitative
explanations concerning political, institutional, and sometimes cultural aspects.
1 Other authors have also noticed this: “During the entire period from 1990 to the present, long-term care did not
play any prominent role in social policy reforms and was widely ignored as a social risk” (Oesterle 2011).

For the paper, the authors used information drawn from the ANCIEN research provided by
partners from CEE countries2 published as ENEPRI Research Reports. Additionally, the
authors studied national reports written under an earlier EU project on LTC issues:
EUROFAMCARE (Services for Supporting Family Carers of Elderly People in Europe:
Characteristics, Coverage and Usage) and studies by the European Commission, OECD and
the World Bank. The first versions of this paper were reviewed by Monika Riedel and Erika
Schulz, whom the authors would like to thank for their inspiration and suggestions.
6
1. Future demographic changes in old and new
member states of the European Union
New EU member states are countries which, at present, do not differ significantly from the
old EU member states in terms of their demographic structure; some of them have an even
younger structure, which is the case in countries such as Poland and Slovakia. It is worth
noting that in Hungary, Bulgaria, Estonia, and Latvia, however, the share of the elderly is
already high (see the graph below). Negative net migration represents a significant factor
contributing to the high share of older people in the Baltic countries, Bulgaria and Romania.
In turn, Hungary is the only country in the region where processes related to the so-called
demographic transition and accompanying ageing of the population started earlier, similarly
to the old EU member states. Hungary was obliged to take the implications of that fact into
consideration when developing its social policy, especially as related to pension policy.
The demographic structure will undergo rapid changes. Each successive decade will bring
growth in the share of the old and oldest people in the total population. The following graphs
present these changes as compared to the average for the old EU member states.
2 Czibere and Gal (Hungary), Ilves and Plakane (Latvia), Golinowska (Poland), Mincheva and Kanazireva
(Bulgaria), Marcinkowska (Lithuania), Paat, Marilain (Estonia), Popa (Romania), Radvansky and Palenik
(Slovakia), Rupel and Ogorevc (Slovenia), Sowa (the Czech Republic)

Figure 1. Persons aged 65 + in the population in 2010 and in the future: 2020, 2030,
2040, 2050 and 2060
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EU15
EU27
Slovakia
Poland
Romania
Czech Republic
Lithuania
Slovenia
Hungary
Latvia
Bulgaria
0.0% 5.0% 10.0% 15.0% 20.0% 25.0% 30.0% 35.0% 40.0%
Estonia
2060
2050
2040
2030
2020
2010
Source: based on data from Eurostat 2011
In 2050, as shown in the forecasts, the share of people over 65 years of age in countries
such as Bulgaria, Slovenia, Slovakia, Latvia, and Poland will exceed 30%, while the average
in the old member states will be less than 25%. The share of people in the oldest population
group (80+ years old), characterized by a higher risk of dependence, will exceed 10% in a

number of the old member states and a few new ones: in the Baltic States (except Estonia),
Bulgaria, and Slovenia. However, 10 years later, in 2060, the share of people over age 80
will exceed 12% in almost all European countries.
Figure 2. Persons aged 80+ in the population in 2010 and in the future: 2020, 2030,
2040, 2050 and 2060
8
EU15
EU27
Slovakia
Romania
Poland
Czech Republic
Lithuania
Bulgaria
Latvia
Slovenia
0.0% 2.0% 4.0% 6.0% 8.0% 10.0% 12.0% 14.0%
Hungary
Estonia
2060
2050
2040
2030
2020
2010
Source: based on data from Eurostat 2011

As a result of future demographic changes, the old-age dependency ratio will increase
dramatically. As a matter of fact, it will double. From a share of approximately 25% today, it
will increase, reaching more than 50% in 2050; in Slovenia, it will even come close to 60%.
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Table 1. Dependency ratio in 2009, 2030 and 2050
Countries Demographic old age dependency ratio*
2009 2030** 2050**
Bulgaria 25.2 36.3 55.4
Czech Republic 20.5 35.7 54.8
Estonia 25.2 34.4 47.2
Hungary 23.8 34.1 50.8
Latvia 25.1 34.6 51.2
Lithuania 23.2 34.7 51.1
Poland 18.9 36.0 55.7
Romania 21.3 30.3 54.0
Slovakia 16.7 32.3 55.5
Slovenia 23.6 41.0 59.0
EU 27 23.6 38.0 43.9
* share of people aged 65+ in relation to those aged 15-64
** data for years 2030 and 2050 is derived from Eurostat ‘Europop 2008’ demographic projection
Source: Eurostat 2011
2. The notion of long-term care
In light of the fact that population ageing has now become the main theme of social debate
on the future, following the example of Western Europe countries, CEE countries have also
started using the concept of LTC. When explaining why LTC should be considered
separately (from other forms of care), it is argued that LTC is a solution which is used to
cover a new social risk, that is distinct from the types of social risk defined in international
and domestic regulations pertaining to social protection (European Commission MISSOC
2009.) This risk concerns being dependent in old age and requiring constant
assistance from another person to be able to perform basic activities of daily living.
The risk of becoming dependent is regarded as a risk that is different from the risk of falling ill
or becoming disabled, even though chronic disease/s (physical and/or mental) and
progressive disability may be at the root of this risk.
LTC is defined in institutional terms as a cross-cutting policy issue that brings together a
range of services for a person who is dependent on others for help with basic activities of
daily living over an extended period of time (OECD 2005.) It should be perceived (and indeed
sometimes is perceived) as a distinct part of social protection, integrating existing and

emerging institutions and solutions which address the care and nursing needs of the elderly.
However, in many cases the precise definition of existing and emerging institutions to be
included in this set is still lacking, and – consequently – there is no definition of financial and
human resources that may be attributed to this category.
LTC services provided for senior citizens who are dependent on help may be nursing- and
rehabilitation-oriented in nature, but they may also be focused on the provision of care and
assistance in daily living. With regard to the provision of case, certain medical qualifications
are required, so such services are typically rendered by nurses and rehabilitation specialists
(or physiotherapists.) Daily living services tend to consist of social work and as such, are
provided by social and socio-medical worker, who combine certain elements of medical and
social care skills. In many countries, such combined qualifications are only just emerging as
separate qualifications in the process of professional development and training.
Many countries classify LTC either under the “umbrella” of the health care sector or the
social sector (most commonly, social assistance). However, in light of its two-fold nature
(both medical and social) and the unique needs of the elderly dependent on help, it would
seem justified to distinguish long-term care from other forms of care within the social
protection system. The lack of such a distinction hinders the task of service identification.
One especially important point is that it is hard to define long-term care needs. Moreover, it is
not clear which sectors of the population of those in need of long-term care are included in
the social protection system. There is a lack of relevant statistical data and the monitoring of
the ageing process and the policies addressing the problems of the elderly has been
inadequate.
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3. Development of care for the elderly
The development of care for the elderly can be seen from two perspectives: on the one hand,
one can focus on the development of formal care, the importance of which has grown with
increasing human longevity and the development of medicine and rehabilitation techniques,
which improve the lives of the elderly population; on the other hand, one can concentrate on
the reduction in informal care, especially within the family due to social transformations and
changes on the labor market and in the situation of women.
Development of formal care for the elderly

Formal care for dependent elderly people became a recognized medical activity at the
beginning of the twentieth century. “Geriatrics” was considered a sub-specialty within internal
medicine. It was formally introduced by Ignatz Leo Nasher, a Viennese doctor working in
New York. He founded the world's first Geriatric Society, which began publishing a
specialized journal called "Geriatrics". At that time, the first geriatric unit was created at the
university hospital in Prague, along with Masaryk homes in Krc (Holmerova 2004), a health
and social care institution.
In Poland, the first health care institution for elderly people with limited capacity for
independent daily living was established in 1956 in Inowrocław: a geriatric sanatorium3. It
soon became a training base in the field of geriatrics. In the other CEE countries, geriatric
units at health institutions were created a little later: in the 1960s and 1970s.
Throughout the 20th century, care for dependent elderly people was seen as a predominantly
medical activity. The medicalization of care was particularly evident in the period following
the Second World War in the former socialist countries. Social issues within the framework of
so-called “social and cultural activity” did not include issues of health, disability, and poverty.
According to the prevailing ideology, difficult social situations could not have social
determinants (because socialism had successfully eliminated these), but they were the result
of one's individual fate and were related to health and/or disability (Zalewski 2004).
Therefore, not only treatment, but also disability and dependence, were the domain of the
Department of Health (the full title of which also included “Social Welfare”). For 40 years
(between 1948 and 1989), with the increasing conformity to Communist ideology, human life
under socialism became more and more institutionalized and care for dependent older
people was provided mainly in hospitals and other health sector institutions4.
A change in the approach to care for dependent elderly people took place in the 1990s along
with the general systemic changes. In all of the former socialist countries, social welfare was
separated out and, to a suitable extent, 'removed' from the health sector. The range of social
welfare was determined and statutory regulations were introduced (first in Poland in 1990,
then in Hungary in 1993, in the Czech Republic in 1997, and in Bulgaria in 1998). In this way,
a separate sector of services was created, aimed mainly at people with special social and
health problems, as well as the poor. Only care for chronically ill and dependent people
requiring a range of medical interventions remained within the health sector, despite the fact
that the prognoses for recovery and regaining independence were not favorable in such
3 The first Polish geriatric clinic was established in 1960 in Opole. A year later the first two geriatric hospital units
were created in Katowice and Lodz (Derejczyk et al. 2009).
4 In Poland, church and religious centres, usually run by religious orders, have played a role in providing care for
dependent persons and bedridden patients. They regained the right to conduct this kind of activity independently
after 1956, a right of which they had been stripped during the Stalinist era (in the early 1950s).
11

cases. Initially, such persons remained in special wards in hospitals. Over time, a network of
long-term care facilities was established for such patients. In this way, hospitals were
relieved of the burden of expenditure on those who did not require expensive medical
treatment, but rather needed long-term care. As a result, care for dependent elderly people
is situated in two sectors: (1) the health care sector, which includes cases of dependency
care, requiring a range of medical services; and (2) the social sector, which includes care for
dependent elderly people who are also in a difficult situation: they are alone, come from
dysfunctional families, or are poor.
With the introduction of market mechanisms (the deregulation of prices, economic freedom
and privatization etc.), private entities offering nursing and care services for those in need
(including the elderly) started to appear in the 1990s. Private institutions are becoming more
and more numerous, especially in Poland, the Czech Republic, and Hungary. More and more
senior citizens are taking advantage of the services they offer. Private institutions are not
always commercial. Some of them are run by non-governmental organizations and are not
profit-oriented. The participation of NGOs in providing long-term care also varies regionally.
For example, in Poland there are regions with a traditionally higher share of NGOs operating
in-patient care institutions, e.g. the Lesser Poland region (Mikos 2010).
Private institutions do not always have a good reputation because their service standards
vary and are not always disclosed in the offer. As the quality of care services is subject to
either no supervision or inadequate supervision5, the development of the private sector in this
area would require a significant change in the quality control of services in the entire field of
long-term care based on defined and implemented standards.
Another important factor affecting the development of long-term care in the post-communist
countries is the decentralization of government and public administration. Decentralization
reforms meant that the responsibility for the organization of long-term care became the task
of local government. At the same time, however, the substantive responsibility for the form
and content of care and its financing remained the responsibility of the health care sector.
This caused difficulties in the coordination of actions, which - in some countries – have been
‘offset’ by special regulations on the operation of social services at the local level
(parliamentary acts on social services: e.g., in the Czech Republic and Lithuania). In other
countries, these problems still occur (e.g. in Poland).
The diagram below shows the complexities of formal care for dependent elderly people.
Despite the impression of a multiplicity of solutions, suggesting a lot of options, access to
5 In many countries, the media have been revealing the scandalous treatment of residents in private nursing
homes, which has resulted in dwindling support for the development of this sort of facility from politicians and the
local communities, even if the cases focused on by the media are only isolated and most institutions function
properly.
12

long-term care is very limited. This includes de facto only severely dependent people who
require a range of medical services6, and people in extremely difficult economic situations
with many social problems.
Senior
houses
senioró
w
13
Long-term care
Long-term-care
Public Private
Social sector For profit
S
& non-profit
Family care
assistance
Home care
services
Community
home care
Health care
sector
Community
& home care
Residential
LTC facilities
Development of informal care for the elderly
Social
assistance
homes
In the less industrialized countries of Central and Eastern Europe, care for children and the
elderly remained within the family domain. After the Second World War, during in the period
of accelerated industrialization taking place under the socialist system, the role of the family
declined. However, in terms of the pace, the process proceeded differently in different
countries of the region. The reduction in the caring functions of the family was more
pronounced in the more industrialized countries which had a higher proportion of women in
the labor market, such as the Czech Republic.
6 In the post-communist countries, the practice of providing health services related to the human body is strongly
medicalized. According to custom and to regulations in the health sector, only licensed medical professionals can
provide such services.

The institutionalization of social life predominantly concerned children, young people, and
workers and their families, rather than older people. This different approach to the elderly as
compared to children was particularly characteristic of Poland7. It was commonly accepted
that the responsibility for caring for a person in the final stages of their life was the task of his
or her family. At the same time there was a push to increase the education and “professional
activation” of women.
How was the conflict between family responsibility and increased female professional activity
resolved in real life? The reconciliation of work and care tasks was facilitated predominantly
by state regulations – mainly the possibility of early retirement. Women with a legally
sufficient employment record could retire at the age of 55, which was taken advantage of on
a massive scale. In the former redistributive pension system (still in existence for some
cohorts born before 1949), the impact of one’s employment record on his or her pension
level was not significant to motivate against early retirement.
The tacit assumption that the family who should provide care for dependent elderly did not
undergo a significant change in the years 1990 - 2010, despite the fact that the demographic
trends, as well as labor market conditions were not favorable. The demographic potential for
providing care services8 decreased steadily (see chart), which was clearly visible in the Baltic
States, Slovenia, Romania, and Bulgaria. At the same time, women sought to maintain their
high level of professional activity (characteristic of the former socialist countries) in the so-called
“immobile productive age” (45 - 59), with the exception of Poland.9 A reduced
14
employment rate remains the case in Hungary and Slovenia (Eurostat 2011).
7 Hungarian experts claim that this obligation of the family concerning care for older people was reflected in legal
provisions (Family Act, 1952, and 1986) which obliged the family (not just children) to assist the elderly in need
(Szeman 2004).
8 The indicator of care potential is defined as the ratio of the number of women aged 50-69 to the number of
people aged 70 and more.
9 In Poland, only highly-qualified women were professionally active for so long. Those with lower qualifications
and those employed in industry benefited from many forms of early exit from the labour market, which, in the
period of rapid transformation, were more numerous in connection with the social protection policies for the
restructuring economy.

Figure 3. Indicator of women's potential for provision of care services in the years
1990-2010
15
1.3
1.2
1.4
1.5
1.6 1.6
1.7 1.7 1.7 1.7 1.7
1.9
1.0
0.9
1.3
1.2
1.5
1.1 1.1
1.3
1.1
1.1 1.0
1.1
2.0
1.8
1.6
1.4
1.2
1.0
0.8
0.6
EU27
EU15
Czech Republic
Hungary
Slovakia
Latvia
Estonia
Poland
Bulgaria
Slovenia
Lithuania
Romania
1990 2011
Source: own calculations based on Eurostat data
The transition period, with its numerous market solutions (including solutions in the field of
elderly care) resulted in the concept of financial support for the elderly in the form of an
attendance allowance that would enable them to choose the sort of care they preferred: the
purchase of private services or the option of partial compensation to a family for the care
they provide. However, attendance allowances are usually amounts that are very small and
do not, de facto, allow for the purchase of care services. In some countries, they are
awarded on the basis of an income test. Consequently, informal care is still predominant and
occurs within the family. As shown in the studies, in the last decade, the participation of
immediate family members in the care of the elderly has not diminished, and in some
countries it has even increased quite a bit (for example, in Poland - CBOS 2012). Older
people have continued to benefit mainly from the care provided by spouses, children (mostly
daughters or daughters-in-law), and grandchildren.10 In cases where they used the services
of persons outside the family, in most cases, these services were provided by persons
employed in the shadow economy, usually immigrants.
10 The structure of care-providing family members is not homogeneous; in Poland these include mainly children
(63%), followed by spouses and grandchildren (38% - 29%) [CBOS 2012]. In the Czech Republic, the
participation of spouses, siblings, and extended family is greater than in Poland.

Using the services of immigrants is still a characteristic of large cities in the new member
states: Budapest, Prague, Warsaw, or Krakow. Such services are subject to a certain degree
of social control. Usually, there is a limited network of contacts that allows persons seeking
carers to reach a foreign carer and learn about her credentials (they are usually female).
Research in this field in Poland (Domaradzka 2004) and in Hungary (Szeman 2012)
indicates that the range of this type of care is not growing; it is, admittedly, small, but steady.
Normally, it is provided by people from ethnic groups of the host country that exist in the
country of origin, such as: in Hungary by Hungarian minorities from Romania (Transylvania)
and Ukraine (Subcarpathia), and in Poland mainly by Polish minorities from western Ukraine
and Belarus.
In parallel, formal home care services are developing, utilizing the pool of family nurses and
carers (often it is a new profession) acting locally. In the World Bank report, this phenomenon
is exaggeratedly referred to as "the strong growth in home and community-based services”
(World Bank 2010). However, formal home care services usually do not replace family care,
but help in the provision of the most difficult elements of care, or even some medical
procedures: for instance, in the case of mechanically ventilated patients or patients on
parenteral nutrition.
Family care is still the basic form of long-term care in the NMS of the EU. The slow but
steady reduction in family participation in care can be attributed to the availability of formal
home care services, which is facilitated by relevant regulations (Act on Social Services) and
programs, such as those in the Czech Republic and Lithuania. The development of
residential care as a result of moving away from hospital care to a new type of health care
facility (nursing care facilities) also reduces the burden on families in the most difficult cases
of dependency. However, this is a very expensive method and it is a burden on the limited
resources of the public health sector. It also burdens the recipients of care (the elderly) and
their families, whose co-participation in expenses is becoming larger and larger; covering the
costs of accommodation and meals has been extended to encompass non-medical care
services.
In all member states, we can observe the equalization of the retirement age for women and
men (from 55 and then 60 to 65 years of age), and there are calls for its further extension to
the age of 67. The decisions made have not, so far, gone hand in hand with significant
changes in the development of LTC for the elderly, who will not be able to depend, to such a
large extent as before, on care from women in their families. The above mentioned
retirement age trend will - as a side effect - increase the pressure on the development of
formal long-term care.
16

17
4. The family–based model of long-term care for the
elderly
The development of long-term care in the new EU countries, where we are observing the
exceptionally deep involvement of family members in the provision of care for the elderly, has
been documented in European comparative studies. On this basis, a proposition was put
forward, stipulating that the LTC social model in that part of Europe be a family-based
welfare regime (Reimet 2009.)
The family-based welfare regime in post-socialist countries applies only to services for the
elderly. As far as children are concerned, we can observe a high level of institutionalization in
all countries except for Poland.11 In a study conducted by Anne Reimet, she noted the high
level of family involvement in the provision of care for the elderly due to two factors: co-residence
of the elderly with an adult child (and that child’s family) and the low level of
professional activity of women at the pre-retirement age of 50-65. It should be noted,
however, that the low level of professional activity of women at that age in the new member
states is not a consequence of the low activity of women in general. Rather, it is a result of a
mass movement of women towards all kinds of solutions involving an early exit from the
labor market with income provisions: disability pensions, early retirement pensions, pre-retirement
benefits and nursing benefits. Under the circumstances, family-based care is in
fact co-financed by the state, albeit not directly, through some kind of income provided to any
woman who is taking care of a family member.
Furthermore, senior citizens in post-socialist countries rely on a social insurance pension
system, which on average provides them with a relatively decent replacement rate. They
transfer it to the family, and in return they feel, in a way, entitled to some kind of care. Family
transfers from senior to junior family members are quite substantial.
11 Due to a different model of country development in Poland under the communist regime, with a high share of
private agriculture and strong family values supported by the Catholic Church, institutional forms of care for small
children were not developed to the same extent as in other socialist countries.

Figure 4. Family-based welfare index in elderly care according to Anne Reimet (2009)
As can be inferred from the figure above, not all of the new member states have higher
indexes than the EU average. In the Baltic (post-soviet) States, the level of professional
activity of women at pre-retirement age is high, despite a high rate of co-residence of old
people with their children (see Table 2.) The reasons are both fewer opportunities for income
provision after opting out of the labor market and substantial losses in the amount of income
(present and future) after retiring from professional activity.
18
5. Long-term care – a female world
As demonstrated by Manfred Huber (2009) in his comparative report, one outstanding
characteristic of long-term care services is the fact that those who provide care and those
who receive it are mostly women.
By and large, women are the ones who provide family care. There are qualitative studies
describing the forms and conditions of family care, but there is a lack of comparative
quantitative studies which would provide relevant estimations. Provision of care for the
elderly is reflected, with some approximation, in the indexes of the less intensive presence of
women on the labor market at a more senior age of professional activity (55-64.) The role of

family care-givers in old European countries has been decreasing because women at pre-retirement
age are more and more professionally active (European Commission 2009). The
employment rate of women aged 55-64 is still significantly lower than that of men. The so-called
'gender gap' within this age group is still larger than the average: 16 percentage points
against 12. The situation varies among the new EU member states. In the Baltic states, the
employment rates of men and women at all ages, including the pre-retirement age group, are
similar. In Estonia and Latvia, the employment rate of women is higher than that of men. On
the other hand, in Poland, Slovakia, Hungary, and Romania, the employment rate of women
aged 55-64 is only 24% - 33% and is significantly lower than the employment rate of men. It
is also and lower than the average for both men and women.
In the Eurostat analyses concerning employment, using research on professional activity
(LFS), the question of why women aged 55 were leaving the labor market was asked a
number of times. Women in the new member states replied that it was due to the possibility
of retiring or being granted disability benefits (80 - 90%). Only a small fraction of respondents
said it was due to the lack of jobs (European Commission 2012).
Since women generally tend to live longer than men, they are at greater risk of disability in
the final years of their lives. Women constitute two thirds of the approximately 4.7% of the
population aged 80 or older. According to OECD analyses, the gender gap with regard to
women who receive assistance and nursing care at that age is substantially higher, but not
as high as it could be if it were proportional to the demographic gender gap. In the most
affluent countries which have the longest life expectancy, the gender gap amounts to a
dozen or so percentage points. In the slightly younger cohorts (65-79), the share of people
who receive assistance and nursing care is much lower and distributed more evenly across
genders (Fujisawa, Colombo 2009, p.19.)
Moreover, women constitute the vast majority of those who work as nurses and social
assistants. Amongst the several major professions/occupations with a female predominance,
health care and social care services are among the leaders, i.e. the most ‘feminine’ sectors
of the economy, following sales, cleaning and personal services, and education (Eurostat
2007). The outcome of the quantitative assessment of the tendency, obtained through a pilot
OECD study (2008), presents indicators with the share of women at the level of about 90%
or more.
However, this traditional female world of LTC services has been somewhat disturbed. The
female inclination towards training in nursing and medical care services has become less
and less pronounced. It is a difficult and relatively low-paid profession, with a high rate of
burn-out and a hardly motivating career path. For these reasons, nursing and care services
19

in more affluent countries are provided more and more frequently by female foreigners. For
example, in Germany and the UK, about 30% of care-givers in formal care are foreign, and if
informal care were taken into account, the ratio would be much higher. In the period of 1995
– 2006 in OECD countries, the tendency to hire foreign female workers in long-term care was
on the rise. The qualifications of women who provide care are typically low, and they are
much lower in the social sector than in the health care sector. They are also lower in informal
care versus formal care (Fujisawa, Colombo 2009).
The CEE countries are still a source of migrant nursing workforce for the old EU countries,
although this trend is weakening12. The number of educated nurses per 1000 population is in
fact low, much lower than in Western Europe; this is especially the case in Poland, Romania,
and Bulgaria (see table). At the same time, in the new EU member states, the demand has
begun to increase for care services for dependent older people, which has further contributed
to increased tensions on the nursing labor market (protests and strikes). As a result,
decisions have been made concerning the education and training of carers for long-term care
services, and concerning a gradual increase in nurses’ wages - which are still relatively low,
below the average wage in their countries (OECD 2010).
In new EU member states, the demand for assistance and nursing care for older people who
are dependent on help has already started to grow, leading to an increase in domestic pay
rates for those working in these professions and an inflow of foreign female workers to big
cities in the CEE region, such as Prague, Budapest and Warsaw.
20
Table 2. Women’s potential for care service provision and care service needs
Countries Rate of employed
persons aged 55-64
(2010)
Share of persons aged
80+ by sex in the
population
2010
Number of nurses per
one thousand residents
(2008)
Female Male Female Male
Bulgaria 37.7 50.3 2.4 1.4 4.2
Czech Republic 35.5 59.6 2.4 1.1 9.7
Estonia 54.9 52.2 3.1 1.0 8.7
Hungary 30.1 39.6 2.8 1.2 8.7
Latvia 48.7 47.5 3.0 0.9 6.3
Lithuania 45.8 52.3 2.7 0.9 7.1
Poland 24.2 45.3 2.3 1.0 5.2
Romania 33.0 50.3 2.0 1.1 5.5
Slovakia 28.7 54.0 1.9 0.8 6.3
Slovenia 24.5 45.5 2.8 1.1 6.3
EU 27 38.6 54.6 3.1 1.6 9.8 (EU total)
Source: Eurostat 2010 and 2011, OECD 2010
12 In Western European countries, the number of Asian workers in this sector is increasing.

As a result of the demographic changes, the nursing potential of family care is expected to
become severely limited (see chart below). All the more so when we take into account the
fact that, in light of high ageing dynamics and pension system stability concerns, politicians
tend to promote a policy of longer employment, thus shifting the retirement age upwards.
Clearly, we can observe a conflict in social policy directions concerning the elderly population
in the context of the longer presence of women on the labor market. As a consequence of
the fact that the retirement age for women and men is both equal and higher, the nursing
potential of women in family care is becoming less available. A strong need for the
institutionalization of LTC services is becoming apparent, both in terms of care provided at
home and in specialized facilities. It is a huge challenge that can probably be successfully
addressed, but only assuming a much deeper involvement of social policy in this segment of
social protection than there has been to date.
21

Figure 5. Indicator of women's potential for care service provision – forecast for the
next decades 2020 – 2060.
22
0.0 0.2 0.4 0.6 0.8 1.0 1.2 1.4 1.6
EU27
EU15
Estonia
Slovenia
Latvia
Lithuania
Bulgaria
Romania
Hungary
Poland
Czech Republic
Slovakia
2060
2050
2040
2030
2020
2010
Source: own calculations based on Eurostat 2011 data

23
6. Introducing long-term care into social protection
legal regulations
In the post-socialist countries, long-term care is not a separate division within social security.
However, in most of these countries, we are seeing a slow evolution of social legislation
towards identifying selected institutions to provide long-term care. We can see a tendency
that consists in separating out long-term care services from existing health services and the
social welfare institutions that are being created. However, this process is still occurring
separately in the health and social sectors.
On the basis of an analysis of the information contained in the national reports drawn up for
the ANCIEN project, one can attempt to formulate a classification based on differences in the
degree of development of long-term care regulations. There are three basic degrees
(stages):
(1) The establishment of more general regulations clearly defining the
policy towards the elderly and dependent persons, defining the
responsibility of the state and other entities for support of nursing and care
functions, and suggesting relevant institutions to perform these functions.
(2) The determination of long-term care as one of the tasks of, on the one
hand, the social welfare system (in development), and on the other hand,
of the local authority, within the framework of the de-centralised power
structures. The new regulations indicate these functions and determine the
conditions for entitlement to long-term care.
(3) The legal regulations rarely indicate, and do not specify in detail, the
function of long-term care in the existing branches of social security and
health care. Traditional names are used: 'social welfare' and 'support of
people with disabilities'. The category of 'long-term care' is used mainly
by experts. However, in the regulations concerning the functioning and
requirements formulated in relation to various entities and their activities,
some guidelines are introduced.
The Czech Republic is in the first group of countries. A general regulation equivalent to an
act of parliament was adopted there with regard to social services, which include care
services aimed at the elderly and persons with disabilities. However, these services are not
referred to explicitly as long-term care services for older people, but more generally as social

services. This act allows the creation of public and private entities to provide various social
services. The Czech Republic is also distinguished by the fact that at the government level, a
programme was developed in order to prepare activities connected to the ageing of the
population: the 'National Programme of Preparation for Ageing 2008-2012'. This program
fosters a greater awareness of demographic changes and their effects and the acceptance of
taking tough steps such as extending the retirement age.
Despite the law on social services, part of these services, both in in-patient and home care,
are still provided within the health care system. In-patient services are provided in long-term
care homes, often created from hospital wards, for long-term patients requiring skilled
nursing and specialist medical care. All in all, the long-term care system is not yet fully
integrated and is managed under the Czech Ministry of Health and the Ministry of Labour
and Social Affairs (Sowa 2010).
Innovative integration solutions can also be observed in Slovakia and in Hungary, where a
local project has been developed aimed at the integration of social and health care systems
– the ISZER (Integrated Social and Health System). Integrated care programmes are
oriented towards home care, within the framework of which various services operate,
depending on needs. The use of an integrated approach is also planned in Estonia.
The second group of countries includes Lithuania, Latvia, Bulgaria, and Romania. In these
countries, there are no separate regulations on long-term care for the elderly. There are,
however, regulations concerning care in general (for those suffering from diseases, people
with disabilities, and the elderly) and the operation of centres providing support, as well as
nursing and care services. These regulations define the tasks and social activities of local
authorities. At the same time, regulations concerning social welfare and the decentralization
of the state's system of power and administration have also been formulated. One might say
that in this group of countries, long-term care is defined more in social than in medical terms.
The level of co-payment by the care recipients is significant. Facilities providing long-term
care services at the local level may receive a budget grant from local authorities if they meet
certain standards (in Bulgaria, these were defined in 2008 as 'financial support standards per
one place').
Older people requiring long-term care services of a more medical character are still patients
in the healthcare system (e.g. they usually use the services of special hospital or para-hospital
wards). Receiving long-term care services in the case of chronic diseases and
dependence requires a medical certificate. The term 'long-term care system' is not used in
the legislation and operates only as a term adopted by expert groups.
24

The third group of countries includes Poland and, partially, Hungary. These countries do
not have any general regulations on long-term care for the elderly either. At the same time,
various public and private institutions that provide long-term care services are functioning or
are being set up. These institutions operate under a number of laws: the law on health care
centres (healthcare), the law on social assistance (nursing homes), the law on public benefit
organizations (NGOs), and the act on the freedom of economic activity (commercial
facilities). With regard to home care activities, the law on health care services and on the
nursing profession applies. It allows nurses to provide nursing care as community
nurses/health visitors. This type of development of long-term care has been referred to as
supply-oriented, because the state encourages the creation of facilities and services, and is
less concerned about the ability of the recipients of care services to pay for the services
offered. In Poland, a project was discussed concerning a method of insurance-based funding
of such facilities (draft by Senator Augustyn), but for now it remains in the parliamentary
“deep-freeze”.
25
7. LTC organization and management
Institutional development in Central and Eastern Europe countries is still undergoing
transitional changes, which means that governance and coordination in many areas of
economic and social life remain in statu nascendi. From the standpoint of social services
(including long-term care), a lot of attention should be devoted to the process of
decentralization. A key role in social policy implementation is assigned to the emerging (and
re-emerging) local and regional self-government authorities. Having said that, self-government
authorities do not have adequate resources as of yet; they lack the funds,
manpower and competence to effectively execute the tasks they have been assigned. As a
result, numerous social policy solutions lack an effective coordination platform and they are
not adequately monitored or regulated under relevant provisions. Long-term care is one such
area. The specification (table) below specifies key institutional actors and their LTC
accountability.

26
Specification 1. Accountability for the organization and delivery of LTC
Actor Accountability Area of accountability Country
Central government General Regulations, strategies,
standards, professional
education, financing
principles, resources for
regional and local
government units
All analyzed
countries
Health care sector Institutional care, home-based
nursing care
Rules governing access
and service financing
All analyzed
countries
Social sector Socio-medical
institutional care, home
care
Rules governing access
and co-funding
All analyzed
countries
Regions Regional LTC policy Institutional network
development, cohesion
policy
Hungary and
Slovakia
Local government Residential, day,
community and home
care
Needs identification, co-funding,
co-management,
development of
infrastructure, service
delivery
Most of the
analyzed countries
NGOs Fundraising and
sponsoring LTC services,
LTC delivery
Service delivery in
cooperation with local
government
Czech Republic,
Poland, Slovakia,
Hungary and
Romania
Source: Author’s compilation
As far as the development of social services is concerned, there were high hopes in the post-socialist
countries related to the development of civil society and non-governmental
organizations. In the initial phase of the transition, NGOs mushroomed in the prevailing spirit
of democratization in political and social life, together with the introduction of regulations on
the freedom of business activity, assembly, speech and state support for NGOs. Today,
after two decades of transition, the lessons learned from the development of NGOs are not
all optimistic. One cannot overlook the significant difficulties in their development path. Stable
organizations are more common in countries which have had some previous experience in
non-governmental forms of social assistance: those connected with the church (e.g., in
Poland), hobbies and pastimes (e.g. in the Czech Republic), or established in response to
political oppression (for example in Poland and Hungary). As far as long-term care is
concerned, the Catholic Church, monastic orders, and religious organizations (e.g.
CARITAS) still play a significant role. ‘Lay’ organizations have focused on the needs of
disabled children and adolescents. It should be noted, however, that the main focus is
centered on the generosity of the general public in terms of fundraising and sponsoring some

residential institutions that deliver LTC services rather than on ‘grass-roots’ initiatives aimed
at building organizations which could provide such services themselves.
27
8. LTC funding
In light of the fact that long-term care functions in CEE countries are performed within several
different segments of the social and health protection system and by various institutions, in
order to be able to get a good overall picture of the financing of LTC functions, one needs to
aggregate various streams of funding utilized for LTC purposes in different places.
Aggregation by itself is a simple procedure, but its components are not easy to identify. The
amounts consumed by long-term care are not separated from the overall budgets of
institutions involved in other types of activities as well. The specification (table) below
indicates the institutions involved in long-term care and their sources of funding.
Specification 2. Institutions involved in long-term care delivery according to sources
of funding
Institutions Source of funding Co-payments Country
Wards in general
hospitals: specific and
non-specific
Health insurance fund
or directly from the
state budget
Informal
Formal
Poland, Lithuania,
Hungary
Czech Republic (since
2008 ), Bulgaria
Nursing and care
facilities in health care
sector
As above - Provided free of
charge
- Covering the costs of
accommodation
- Broader scope of cost
sharing
Slovenia
Poland, Czech
Republic
Bulgaria, Estonia,
Slovakia (means
testing)
Hospices Health insurance and
sponsoring
Cost sharing, formal or
voluntary
Poland, Czech
Republic
Institutional care
facilities for older
people in the social
sector:
- residential
- day care
Central budget and
territorial government
budgets (from general
taxation)
Formal cost sharing
Income-dependent
Czech Republic and
Slovakia
Poland, Slovakia,
Slovenia, Hungary
Community nurse
services
Health insurance and
local budgets
- Informal
- Formal cost sharing
Poland, Czech
Republic, Slovakia,
Slovenia, Hungary,
Bulgaria, Estonia,
Non-public
organizations:
- non-profit
- commercial
Contracts with regional
and local self-government
units
Cost sharing, voluntary
payment or full
payment
Poland, Czech
Republic, Slovakia,
Hungary, Romania

28
Institutions Source of funding Co-payments Country
Family Family income and
income of care
receivers (old-age and
disability pensions)
State financial support
in the form of care
allowances for the
caregiver and/or care
user
All analyzed countries
Source: Author’s compilation
Taking into account LTC financing in many places and from many sources, the full cost of
spending (public as well as non-public) on LTC services would appear to be as follows:
Total LTC = [Shc + Hhc] + [Ss+Hs] + N + Ic + Ip
where:
Shc – spending on in-patient care in the health care sector (in hospitals and other facilities)
Hhc – spending on home nursing care, delivered and financed in the health care sector
Ss – spending on in-patient care in the social sector
Hs – spending on home care, delivered and financed in the social sector
N – spending on in-patient and home care delivered by NGOs (including services subsidized
from public funds)
Ic – co-payment from recipients of care services and their families
Ip – personal income spending on LTC services delivered informally (care-givers hired to
work at home) and provided by commercial facilities.
Moreover, a comprehensive evaluation of LTC funding should also include earmarked
benefits supporting the income of the population, including a general indication as to the
purpose of a cash benefit as well as income conditional upon meeting a specified
requirement.
A comprehensive evaluation of expenditures on LTC services requires many estimations,
because the amount of resources allocated to care services for the elderly are not
distinguished (listed separately) either in health care or in the social sector, which presents a
serious barrier to the disaggregation of financial data according to age. Furthermore, it would
be almost impossible to disaggregate the data according to the type of service delivered to
patients, both in terms of health care and social care. Separation of LTC services from
hospital services represents a particularly difficult challenge, and it is a well-known fact that

in the countries of the CEE region, hospitals are still heavily involved in the provision of
nursing and care services.
The structure of spending on LTC services in CEE countries is varied and volatile13, which
demonstrates that the sector is still in a state of flux (in statu nascendi) and each country is at
a different stage of the process of separation and stabilization of the sector.
In the Czech Republic, expenditures incurred in the medical sector are dominant, both in
terms of institutional care and home nursing care. Expenditures on social services and
institutional care (in senior citizen homes) are smaller by almost half. Institutional care
involves a significant co-payment component, which represents, on average, about 20% of
total spending on social services directed mainly towards older people according to data from
the Czech Ministry of Labor and Social Affairs. In recent years, there has been a tendency
towards developing home care services in an effort to support the family in the delivery of
care. Such benefits were defined in detail in the 2006 Social Services Law. One should note,
however, that the share of family care in the delivery of care for the elderly with limited
capacity for independent daily living is lower in the Czech Republic than in other CEE
countries. Likewise, the co-residence index for older persons living with their children is lower
as well.
In Slovakia, the health sector resources allocated to long-term care services are crucial to
the total formal expenditure. In the social sector, an important element of financing is the co-participation
of the recipients of care services in the expenses, the scale of which depends
on their income. Approximately one-third of the costs are covered by such co-participation.
An unusual solution in subsidizing long-term care institutions from health and social
insurance (regardless of the facility's public or private ownership status) is co-participation in
costs according to an amount dependent on the level of fitness and dependency of the
recipients of care services, as assessed by appropriate tests (Radvansky, Palenik 2010).
Within the framework of family care, it is possible to support a guardian of a dependent
elderly person (when a relevant medical certificate has been obtained) with a suitable
allowance, as defined by the support system for people with disabilities. Since 2009,
Slovakia has created centers for fully-integrated care, providing both health and social
services, which are funded in a way that integrates multiple sources. This solution is new and
its success has yet to be fully evaluated.
Hungary does not differ from other post-socialist countries in terms of the organization and
funding of long-term care services. In-patient services for most dependent persons are
financed from health insurance funds. In the social sector, an important role is played by the
29
13 Which is known from in-depth country reports published as ENEPRI Research Reports 2010 and 2011

local government, which is already funding 46% of total spending on long-term care,
including in-patient, out-patient and home-care (Czibere, Gal 2010). Recipients of care
services co-participate in expenses for services, depending on their income and the type of
services needed. The role of the family in the care of elderly dependents is significant.
However, in Budapest, paid external assistance is also widely sought. Family caregivers can
receive benefits, the conditions for which are defined within the framework of the support for
people with disabilities. Being able to obtain a certificate from a family doctor plays a
significant part in being granted such an allowance.
Slovenia is one of the new EU member states where spending on long-term care services is
the highest; it is similar to the relative level of expenditure in the old EU member states
(about 1% of GDP). These services, like in other countries, are provided separately in the
health and social sectors (both within the framework of social welfare and as part of local
social activities for the benefit of residents who are in need). The largest part of the funding
comes from health insurance, which fully finances in-patient care, being part of the system of
primary health care (family doctor). Other costs of long-term care services are covered by
local budgets. Home care services are a significant part of that spending. Family caregivers
receive allowances as part of benefits for people with disabilities.
In Poland, the biggest share of resources continues to be allocated to cash benefits
subsidizing the incomes of the older population, with a special emphasis on care-related
needs. This is consistent with the tendency towards an overriding share of family
efforts in the provision of care and of family spending on informal and commercial services.
On the other hand, due to insufficiently developed specialized facilities and LTC services, a
significant proportion of care is still delivered in hospitals. The emphasis on hospital services
is additionally reinforced by the fact that they are free-of-charge. Facilities established on the
basis of hospitals and operating within the health care sector have introduced payments, but
at a rate considerably lower than the rate for facilities administered outside the health care
sector. Expenditures by the social sector and self-government units come third. This area is
not transparent; there are different regulations and various practices. It seems, however, that
in the future, the above mentioned first two types of LTC services development will be
reduced, and the third type, i.e. services at a local level, arranged on the basis of a public-private
mix and support from regional and local budgets, will expand and grow. However, a
“civilized” development of this sector requires enormous attention and focus from the state in
terms of design and a consistent implementation of high quality standards, development of a
level network of accessible facilities, and investments in nursing and care-giving personnel.
In Lithuania, long-term care services are delivered mostly without payment in a family
setting, except for in cases where the person is heavily dependent on other people’s
30

assistance (including nursing and medical supervision), in which case services are delivered
in hospitals. This is reflected in the level of spending on various types of care in particular
sectors. According to fragmentary data provided by the Lithuanian Statistical Office,
expenditures in the social sector dedicated to cash benefits supporting families who take
care of an elderly person are the highest and have gone up by almost 100% since 2000.
Health care sector spending on institutional and home nursing care is equally high. Just as in
the previous case, the expenditure level has gone up substantially over recent years. The
lowest spending is allocated to assistance with daily duties within the framework of social
assistance, although even in this area, the level of expenditures has increased quite
considerably (by more than 120% in 2000-2007). In recent years, the Ministry of Social
Policy and Labor has decided to focus on the development of non-institutionalized forms of
long-term care, i.e. different types of care services delivered at home. Nevertheless, the
share of such assistance in services for the elderly is so low that a significant proportion of
formal care is provided in hospitals. The private sector plays a marginal role as far as long-term
care provision is concerned. Detailed information on development and spending in that
31
sector is not available.
Latvia's LTC situation is similar to Lithuania’s, although the responsibility for providing LTC
in Latvia is more clearly defined. The state only supports people with appropriate certificates
of disability and dependency and those with serious mental disorders. In recent years, care
services supported by local authorities have been developed and have already overtaken
those provided by the state (Ilves and Plakane 2010). Long-term care (both in-patient and
home-based) can be provided following a very thorough evaluation of the care needs,
circumstances, and material standing of the family in question. The recipients of care
services cover the costs, committing 90% of their income (such as pension or disability
benefits). As the demand for formal long-term care services is high, the government is
supporting the expansion of local institutions providing care services.
In Estonia, there are several solutions that are unusual in comparison to other new EU
member states. Those in need of long-term care services are subject to a comprehensive
geriatric assessment. LTC services are still provided separately in public health and social
welfare sectors, but the introduction of a fully integrated system of long-term care at the local
level is planned, with major responsibility on the part of primary health care (the family
doctor) for the medical component of the integrated service. Family care is to be included in
the integrated system. Family caregivers can already receive assistance (transportation,
housing adaptation enabling the provision of home care, etc.). Long-term care costs are
currently mainly covered by local governments, but plans for the creation of an integrated
system anticipate that the health sector will cover 50% of costs. The share of costs borne by

recipients of care services is high (estimated at 58% of home care) and is expected to
continue to be significant (Paat, Merilain 2010). In the future, it is foreseen that the share of
total expenditure on long-term care will exceed 1% of GDP, whereas the current share is
below 0.3% (op. cit.).
In Bulgaria, long-term care is an element of social assistance and the policy towards people
with disabilities. There are no specific regulations or programmed for long-term care.
However, with reference to social welfare and people with disabilities, there are new
regulations defining the conditions for access and financing and the responsibilities of
relevant bodies for organizing such services (Mincheva, Kanzireva 2010). The role of cost
sharing by care recipients is significant, both in the health sector14 and in the social sector.
As a result, access to formal long-term care for elderly people is limited. Dependent older
people have only themselves and their families to turn to.
Romania is another example of a country where most services are provided informally and
without payment in a family setting. Institutional services (in-patient or day care facilities) and
formal home care services are financed from local budgets and social insurance and when
these resources are inadequate, spending is co-financed from the central budget. Private
resources are derived mostly from non-governmental organizations and co-payments for
institutional care made by nursing home clients. It seems, however, that the key problems
are the inadequate development of long-term care institutions and the extremely low level of
funding for LTC services.
In spite of underlying difficulties in identifying and estimating the cost of long-term care, there
have been attempts to evaluate it in the new EU member states. The table below presents
comparative data derived from various reports: Eurostat, European Commission research
programs, and the OECD. Data varies due to different ranges of activity included in long-term
care for the elderly and due to varied access to data. In some cases, lack of data is treated
as lack of spending.
According to Eurostat, LTC includes care allowances for the elderly in cash as well as
accommodation and assistance in carrying out daily tasks, both in institutional facilities and
at home. Most probably, Eurostat data does not fully encompass the strongly decentralized
social sector, which can only be monitored to a much lesser extent. In turn, in the data
prepared by the Ageing Working Group (AWG), benefits which typically are not taken into
account in other classifications, such as care allowances received together with retirement
and disability pensions in Poland, have been included in the category of long-term care
benefits.
32
14 In Bulgaria, cost sharing of medical services by users was made official with the introduction of the health
insurance reform.

OECD estimations take into account expenditures spent on private services, but they do not
fully include all other expenditures on care and nursing benefits for the elderly from public
funds. Consequently, the estimations presented in the table below are not mutually
comparable. Indicators for particular countries within each attempt at estimation, however,
are more comparable. Such comparisons point to significant discrepancies, both among
individual CEE countries and between CEE countries as a group and average indicators for
the EU - 27, not to mention the EU - 15. Expenditures are relatively higher in Poland and in
the Czech Republic. In Poland, universal cash allowances which subsidize the income of
senior citizens play an important role, and in the Czech Republic spending on in-patient and
home care services has a considerable impact.
Table 3. Estimated public spending on long-term care, health care and social
assistance
Country Spending on long-term care for the elderly as a %
33
GDP
Spending
on health
care as
% GDP
2006
Spending on
social
assistance**
as % GDP
Eurostat
2008
AWG
2007
OECD
2005*
Ancien
WP I 2008
estimation
Bulgaria 0.02 (2007) 0.2 4.5 0.4
Czech
0.26 (2007) 0.2 0.4 0.25 (2006) 6.5 0.5
Republic
Estonia 0.20 (2007) 0.1 - 3.9 0.1
Hungary 0.22 (2007) 0.3 0.3 6.4 0.1
Latvia 0.22 (2006) 0.4 - 3.1 0.1
Lithuania 0.47 0.5 3.9 0.2
Poland 0.37 0.4 0.5 0.23 +
0.5***
4.5 0.4
Romania 0.65 0.0 - 5.0 0.3
Slovakia 0.90 (2006) 0.2 0.3 4.8 0.5
Slovenia 0.68 1.1 - 1,0
EU 27 0.48 1.2 1.3 (EU 15) 7.5 0.3
*data estimated for OECD projection, including public and private expenditures
** social benefits for social inclusion not classified elsewhere (i.e. in social and health insurance, housing policy
and family policy)
*** allowances supporting income of the elderly (universal) and earmarked allowances (nursing)
Source: Eurostat 2009 and 2010, OECD 2006, WHO 2009, Eurostat 2008 – Esspross
In view of the fact that no additional sources of funding (a new/increased contribution or
increased taxation) have been defined in new member states to cover the cost of long-term
care, these costs absorb health insurance as well as social assistance resources. In CEE
countries, the levels of health care sector and social sector spending are relatively low and,
as a result, long-term care funding from the modest resources of both sectors is low as well.
The Czech Republic is, in a way, an exception; it has the highest share of expenditures on
health care and long-term care among all new EU member states, but it is still far below
average EU indicators.

The level of LTC spending over the next several decades has been analyzed in projections
prepared by the Ageing Working Group (AWG.) The projections are based on estimates
pertaining to older people who, due to certain handicaps, will need care. The projections
were made on the basis of information obtained from SHARE15 and EU – SILC survey
studies. The range of LTC services covered in the AWG projections include: institutional
care, home care and cash benefits for handicapped persons and/or their care-givers.
Analogically to other segments of Ageing Working Group projections (expenditures on old-age
pensions, expenditures on health care, etc.), LTC projections have been made for
several alternative scenarios, contingent upon expected changes in population health status,
share and type of formal care, and unit cost of care in future decades. The most important
scenarios were defined as follows:
- “pure” demographic scenario, based on estimations of older people in need of care,
- scenario assuming fewer handicaps and improved health condition of elderly
population,
- scenario assuming decreased share of informal care and increased share of formal
care considered for three alternatives: greater share of institutional care (option 1 in
Table 4), greater share of home care (option 2), and equal distribution between
institutional and home care (option 3). The higher unit cost of institutional care than
home care was an additional assumption.
- scenario assuming an increase in unit cost of care together with an increase in
GDP per capita.
34
The Table below presents the outcome of projections for the four scenarios.
15 The Survey of Health Ageing and Retirement in Europe (SHARE) was conducted in selected EU countries in
2004 and 2006, aimed at describing the socio-economic status of the elderly, their health, disabilities and a need
for care.

Table 4. Projected spending on long-term care as a share of GDP in 2009-2060 (AWG)
35
Country
Base
year
(2007)
„Pure”
demographic
scenario
(2060)
Constant
disability
scenario
(2060)
Switch from informal to formal
care scenario (2060)
Increased
unit cost
with
GDP per
capita
scenario
(2060)
Institutional
care
Home
care
Instit.
& home
care
Bulgaria 0.2 0.4 0.4 0.5 0.5 0.5 0.3
Czech
0.2 0.7 0.6 0.9 0.7 0.8 0.6
Republic
Estonia 0.1 0.1 0.1 0.3 0.2 0.2 0.1
Hungary 0.3 0.6 0.6 1.0 0.9 1.0 0.6
Latvia 0.4 0.9 0.9 1.9 1 1.5 0.7
Lithuania 0.5 1.1 1.0 1.4 1.2 1.3 0.9
Poland 0.4 1.1 1.1 1.2 1.4 1.3 0.9
Romania 0.0 0.1 0.0 0.1 0.1 0.1 0
Slovakia 0.2 0.6 0.6 0.6 0.8 0.7 0.5
Slovenia 1.1 2.9 2.8 3.5 3.2 3.4 2.3
EU-12 0.3 0.8 0.8 1.0 0.9 1.0 0.7
EU-15 1.3 2.6 2.4 3.3 2.8 3.0 2.4
EU- 27 1.2 2.5 2.3 3.2 2.7 2.9 2.3
Source: European Commission 2009
No matter which scenario of long-term care development is adopted, one should expect an
increase in spending levels due to population ageing. The situation where the health status
of the elderly improves and the demand for care does not increase dramatically seems to be
the most favorable. Interestingly, in light of the AWG analyses, the projected increase in the
cost of care is much greater in new European Union member states than in EU-15 countries,
where LTC spending is already much higher.
9. Development of separate and institutionalized long-term
care
The development of separate and institutionalized long-term care can be evaluated on the
basis of two processes: a shift from a family setting to external service provision and the
appearance of external institutions catering specifically to the elderly population within the
social and health protection system. These processes can be described by means of three
indicators: the share of family care for the elderly, the proportion of public care vs. private
care solutions (within the framework of external care) and, last but not least, the proportion of
residential care vs. home care.

The share of family care in the NMS, defined on the basis of outcomes of national and
comparative studies (Reimet 2009), is higher than the EU average, with the exception of the
Baltic States. This is most likely because the Baltic countries, which used to be
incorporated within the USSR, are more institutionalized in the field of social services, which
include care for the elderly, which is reflected in low family and home care indicators.
Interestingly enough, it is in the Baltic countries that adult children frequently tend to live with
their parents, which usually contributes to the delivery of family care. In this case, however, it
does not seem to have such an impact.
36
Specification 3. Model of elderly care
Country
Share of family
care – compared to
average EU index,
equal to 50%
Informal non-family
care
Ratio of paid
institutional care to
paid home care
Bulgaria Quite high – more
than 60%
Limited scope Greater share of using
residential care than
home care
Czech Republic Quite high – about
60%
In some regions of the
country, the share of private
informal care is considerable
As above
Estonia Much lower – 25% Occurs Tendency towards
equalizing the share of
home care and residential
care
Hungary Quite high – more
than 70%
Occurs but its scope is
limited
Use of residential care is
greater than home care
Latvia Lower – about 40% Occurs As above
Lithuania Lower – about 40% No data available As above
Poland High – more than 80% Greater share of
institutional care versus
home care
Romania Quite high - almost
60%
As above As above
Slovakia Quite high – more
than 70%
As above Equal share of home care
and residential care
Slovenia Lower - about 30%;
high employment rate
of women
As above Almost equal share of
home care and residential
care, with strong
promotion of home care
Source: Author’s compilation based on ANCIEN country reports and additional internal country information
A shift from family long-term care to external forms of care is occurring in many different
ways at a varied pace.
To begin with, a shift towards external forms of care may take place without government
intervention or with a very small involvement of the state – by virtue of private solutions. This
may take the form of both residential care (private facilities: commercial and non-profit) and
home-based care, i.e. hiring care-givers and nurses in the household. Poland is one of the
CEE countries with a significant range of private solutions. In Poland, care-givers are hired

by households for LTC services on a conspicuous scale. Also, there are private residential
facilities for dependent clients in old age. It is important to note that such facilities are
established not only in the commercial sector, but are also set up by NGOs and church
organizations.
Secondly, the development of non-family forms of LTC services may be achieved with a
significant involvement of the state, in a regulatory, logistic and financial dimension.
Generally speaking, this process involves the regulation and standardization of care for
elderly dependents, creating special solutions for them, or integrating long-term care into
existing solutions. An example of a country with more advanced solutions of this kind is the
Czech Republic.
At the present stage of welfare state development in European countries, the process of
institutionalizing long-term care consists in the establishment of a separate LTC segment
within the social protection and the health care systems. In the new member states, the
process of the emergence of long-term care as a distinct, separate item is not always equally
advanced among different countries. One can distinguish the following stages of the process:
 LTC services are identified as integrated socio-medical services, but are still
divided between the social sector and the health sector. In the social sector, care
services are defined in special regulations, covering the entire range of social services
(e.g. in the Czech Republic) or only in the field of social assistance. In the health
sector, this entails transferring LTC services to new units in the system of out-of-hospital
37
health care.
 Responsibility for the identification of needs and the organization of services is
shifted to the level of local and regional self-government, which itself is at an initial
stage of development. Decentralization reforms were initiated in the 1990s; they
identified social policy tasks entrusted to local and regional self-government
authorities, but very often they did not equip them with adequate resources needed for
the execution of these tasks.
 Introduction of regulations supporting NGO involvement and sponsorship in
delivering care services for the elderly.
 Actions which formalize and support the provision of care services in the
recipient’s home; standardization and individual plans of care.

 Promoting and exploiting the potential of nurses (primary health care nurses and
community nurses) and training candidates for a new profession – medical care-giver
working with the elderly.
 Introducing quality standards in long-term care provision for quality assurance and
advancement.
 Monitoring and controlling the delivery of LTC services, including the operation of
the non-public sector as well.
 Defining and identifying new sources of funding for separate care services (e.g.
through the introduction of nursing insurance, following the German model.) Given that
expenditures on nursing care services represent a significant part of health insurance
proceeds, the generally low outlays on health care in CEE countries are even lower.
 Defining and implementing comprehensible and socially acceptable rules
governing co-payments from recipients and their families for LTC services.
38
Conclusions
At the time of transition from a centrally planned to a market economy, the formerly socialist
countries experienced numerous market-based solutions, including those in the area of
social services, and focused on the de-institutionalization of social service delivery, with
service provision within the framework of home-based and family care.
The tendency towards the de-institutionalization of lifestyles was more pronounced in relation
to child care than care for the disabled elderly. This was due to the fact that elderly people in
communist countries were not subject to the same extent of institutionalization as the young.
Therefore, family care was the typical solution in cases where the need arose for long-term
care.
Another pattern in the development of long-term care in the former communist countries is
its medicalization. In cases of serious disability that require care services, the elderly would
use hospital care. With time, long-term care services started to be 'moved' out of hospitals
and into nursing homes created specifically for that purpose; however, such services
remained within the scope of the health sector.

The inclusion of long-term care into the social sector took place in the 1990s with the
creation of the social assistance system, including the development of its facilities and the
training of qualified staff.
The decentralization of government and public administration, another process of systemic
change in post-socialist countries, brought about increased responsibility for social issues at
the local level.
At the same time, the idea that family and home care are better than residential care was
widely proclaimed. Family care has always existed and its promotion in a situation where
there is pressure on female occupational activity to grow has caused some irritation. In some
cases, undesirable phenomena also occur within the family such as lack of care, inadequate
care, or even violence16. Furthermore, in conditions of poverty and unemployment, families
have sometimes exploited the elderly financially, not taking their special needs into
consideration; in some cases, a senior citizens' pension or disability benefit has, de facto,
been the family's only source of income.
In reality, the predominance of a certain type of solution is neither easier nor always
desirable (Phillips 2007). Caregivers willing to provide it were required: nurses,
physiotherapists, and social workers. Their training process did not begin until a few years
ago. It should be mentioned that primary health care doctors complain of a chronic shortage
of nurses, as the nurse employment rate in the new member states is very low (see Table 3).
In this situation, primary health care doctors have never been too happy with positions for
independent community nurses.
Home care requires assistance in adapting elderly peoples' homes so that care services can
be provided there. This fact is taken into account only in a small number of countries
(Slovenia and Estonia). The transportation and communication requirements of such people
should also be taken into consideration. Electronic supervision should also be provided.
Investing public and private money in the supply of new infrastructure and new care centers
is proceeding slowly, but steadily. However, a single solution to funding long-term care
services has not been found. In some countries, the recipients of care services and their
families are supported universally, regardless of their income; other countries provide
assistance only in the cases of poverty and an overwhelming need for medical and nursing
care.
39
16 Many international and national studies have been carried out in recent years on abuse of the elderly,
undermining the stereotypical views on the advantages of some specific forms of care over others (Tobiasz
Adamczyk 2009).

The new member states face a great demographic challenge, while still having to deal with
many other problems arising from the transformation processes and, in many regions, from
economic underdevelopment. In this situation, long-term care is an issue that is not
sufficiently taken into account in the countries' social policy and development plans and
strategies. The simplest solutions, both financially and politically, are often chosen. Those
include the promotion of family care and, sometimes, home care, and the development of
private services (home and residential) with decent allowances for seniors.
It appears that the development of residential care and day care in the new EU member
states is inevitable in the near future; also, public funds will be created (e.g. in the form of
special social security for attendance) to supplement care users' income and fund the
provision of care services.
40

41
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